A 4 and Half years old male with bull neck and edema

Dr Ira Shah

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A 4 1/2 years old male with bull neck and edema

Dr Ira Shah.

Medical Sciences Department, Pediatric Oncall, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, Medical Sciences Department, Pediatric Oncall, 1, B Saguna, 271, B St. Francis Road, Vile Parle {W}, Mumbai 400056.

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Clinical Problem
A 4 and a half years old male child presented with fever and one episode of generalised tonic clonic convulsion 15 days back, bull neck 12 days back and edema since 6 days. He was diagnosed as a case of Diphtheria and treated with anti diphtheria serum, steroids, erythromycin, cefaperozone, amikacin and phenytoin and then referred to a higher centre for further manangement of the edema. He was investigated at that centre and the reports are as follows:

Hb: 10gm/dl
WBC: 20,100 cells/cumm
Platelet count: 1,92,000 cells/cumm
Urine: 3+ Albumin, 6-8 RBCS
USG Abdomen: Mild hepatomegaly with mild ascitis and bilateral pleural effusion
Blood urea: 56mg/dl
S.creatinine: 1.56mg/dl
S. cholesterol: 192 md/dl
S. albumin: 3.9gm%
X ray Chest: cardiomegaly with bilateral infiltrates in lower zones

On the basis of the above investigations he was diagnosed as Nephrotic syndrome and given IV albumin.

Should IV albumin be given in such a situation? What would be the further managment?

Discussion
This is where we come back to our basics of nephrotic syndrome. It consists of proteinuria, hypoalbuminemia, hyperlipidemia and edema. This child though has proteinuria and edema does not have hypoalbuminemia and hyperlipidemia. Also, one has not established whether the proteinuria is in the nephrotic range or not by doing the 24 hours urinary albumin or the urine albumin/creatinine ratio. Hence, to proclaim this child as nephrotic syndrome in the 1st place would be erroneous.

Now this child probably had diphtheria though the organism has not been isolated or cultured. Diphtheria can lead to complications as a result of distribution of the organism to any organ of the body. However, it affects the heart, nervous system and kidneys predominantly. This child definitely had a proteinuria and microscopic hematuria suggestive of a kidney involvement with edema though the S. albumin was normal. Another thing that this child had was cardiomegaly on X ray chest with basal infiltrates which may suggest cardiac dysfunction and pulmonary edema either due to myocardial involvement or due to volume overload. Thus here is a situation where IV albumin is not recommended even though the child has edema for the serum albumin is normal and other it may precipitate cardiac failure which actually did occur in this child. Infact this child when investigated for cardiac dysfunction has complete heart block and also myocardial dysfunction requiring ionotropic support.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

Cite this article as:
Shah I. A 4 and Half years old male with bull neck and edema. Pediatr Oncall J. 2004;1.